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Looking In

Every year, students at the Icahn School of Medicine write Op-Ed articles about topics in health care and advocacy to culminate InFocus 4. Charlotte Austin’s article, “Looking In” was one of the 10 exemplary articles selected to appear in the Physicians as Advocates—InFocus 4, and focuses on marginalized identities. We share her story.

You’ve heard the data before: in this country, black infants are four times as likely to die during birth as white infants, and twice as likely to die before their first birthday; Black and Native people have a shorter life expectancy than their white counterparts; and trans people are more likely to attempt suicide than their cisgender peers. Indeed, socially marginalized groups in this country—whether it be due to race, gender, or sexual orientation—are more likely to be unhealthy.

For a long time, medicine has pointed to ‘culture’ to explain these inequities, arguing that black people have higher rates of heart disease because “soul food” is unhealthy or that immigrants are more often sick because they have too many people living in close quarters and have poor hygiene. More recently, science has looked to genetics to explain differences in disease prevalence and health outcomes between groups. To the extent these ideas have some truth to them, knowing them may have some, if limited, value. For example, doctors can educate their patients on healthy behaviors.

But genetics and culture do not tell the whole story, and blaming these things stigmatizes already oppressed identities.

Luckily, things may be changing.

In medical school, we typically learn to explain health disparities in terms of behavior or genetics, but other explanations are gaining traction. For one, the physiologic hardships caused by stress are becoming better understood. It is now well established that chronic stress can cause women to have premature babies or babies with low birth weight. In a class on LGBT health, I learned about “minority stress” – a medical euphemism that, true to its purpose, does not point fingers. (More accurate might be: “being the victim of homophobia or transphobia”). The “social determinants of health” narrative has helped medicine better acknowledge that where a person lives and how much money she has can affect her access to healthy behaviors and health care. There is still a long way to go: for one, the medical establishment needs to become more comfortable naming racism as a risk factor for disease—but it’s a start.

This said, there’s still one area that medicine has great trouble finding fault in: itself. As a second-year* medical student coming to the close of my pre-clinical years, I’m continually surprised and amazed at how little recognition there is that the way that we are taught about something can have a negative effect on our patient’s health. When we learn about men who have sex with men only in the context of HIV and other sexually transmitted diseases, how can we be surprised when we learn that gay patients choose not to disclose their sexuality to providers?

It has long been known that doctors, who are overwhelmingly and disproportionately white, treat patients differently based on their race. Racism is deeply embedded in the American psyche, but medical education must take responsibility for its part in this. We must learn not to pathologize identities, rather than learning to associate being black with kidney and heart disease and being indigenous with alcoholism and obesity. And, significantly, we must increase the diversity of the physician workforce to match that of our nation—at all costs. Medical schools often emphasize the need for better early education to prepare applicants—but this argument ignores what can be done from within. This includes changing admissions criteria (standardized testing is an excellent predictor of one’s ability to do well on standardized tests—and a person’s wealth) and medical education to better suit the needs of a more diverse class.

Finally, when we speak of “access to care” issues in medicine, we act as if this is something abstract and outside of our control, due to issues like poverty and insurance status. We don’t talk about how private hospitals segregate patients into two streams: one, for those with private insurance, where wait times are short and physicians are experienced, and another, for those with Medicaid, where wait times are up to five times as long and patients are more likely to be seen by residents. We don’t talk about how Mount Sinai Hospital has no signs in languages other than English and only one full-time interpreter on staff. We don’t talk about how NYU Hospital had a 90 million dollar surplus while the city’s public hospitals—which provide care to those whom the private hospitals will not—are struggling to be financially viable.

“In medicine, we too often focus on the pathophysiology of disease to the exclusion of social and environmental factors that have as great of an impact on our patient’s health. The experience of writing this op-ed was an important reminder that our role as physicians extends beyond the hospital.”

ABOUT THE AUTHOR

Charlotte Austin grew up in Brooklyn, NY and is a third-year* medical student at the Icahn School of Medicine at Mount Sinai.